Provider First Line Business Practice Location Address:
679 KIDDER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702-6908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-825-3491
Provider Business Practice Location Address Fax Number:
570-822-5654
Provider Enumeration Date:
09/20/2005